Doctors & patients are saying about 'A-Fib.com'...


"A-Fib.com is a great web site for patients, that is unequaled by anything else out there."

Dr. Douglas L. Packer, MD, FHRS, Mayo Clinic, Rochester, MN

"Jill and I put you and your work in our prayers every night. What you do to help people through this [A-Fib] process is really incredible."

Jill and Steve Douglas, East Troy, WI 

“I really appreciate all the information on your website as it allows me to be a better informed patient and to know what questions to ask my EP. 

Faye Spencer, Boise, ID, April 2017

“I think your site has helped a lot of patients.”

Dr. Hugh G. Calkins, MD  Johns Hopkins,
Baltimore, MD


Doctors & patients are saying about 'Beat Your A-Fib'...


"If I had [your book] 10 years ago, it would have saved me 8 years of hell.”

Roy Salmon, Patient, A-Fib Free,
Adelaide, Australia

"This book is incredibly complete and easy-to-understand for anybody. I certainly recommend it for patients who want to know more about atrial fibrillation than what they will learn from doctors...."

Pierre Jaïs, M.D. Professor of Cardiology, Haut-Lévêque Hospital, Bordeaux, France

"Dear Steve, I saw a patient this morning with your book [in hand] and highlights throughout. She loves it and finds it very useful to help her in dealing with atrial fibrillation."

Dr. Wilber Su,
Cavanaugh Heart Center, 
Phoenix, AZ

"...masterful. You managed to combine an encyclopedic compilation of information with the simplicity of presentation that enhances the delivery of the information to the reader. This is not an easy thing to do, but you have been very, very successful at it."

Ira David Levin, heart patient, 
Rome, Italy

"Within the pages of Beat Your A-Fib, Dr. Steve Ryan, PhD, provides a comprehensive guide for persons seeking to find a cure for their Atrial Fibrillation."

Walter Kerwin, MD, Cedars-Sinai Medical Center, Los Angeles, CA


Catheter Ablation

VIDEO: What Should I Expect After the Atrial Fibrillation Ablation Procedure?

Atrial Fibrillation videos at A-Fib.comCardiac electrophysiologist Dr. Darryl Wells talks about judging success of your ablation, why it’s difficult to predict which patients will be completely cured after one ablation procedure and why some require two procedures, safety and the appropriate age range for patients to receive the ablation procedure. (3:17)

Published by Swedish Heart and Vascular Institute.

YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.

If you find any errors on this page, email us. Y Last updated: Wednesday, July 18, 2018
Return to Instructional A-Fib Videos and Animations

VIDEO: The Hybrid Maze/Ablation for Atrial Fibrillation for Persistent A-Fib

For persistent or long-standing persistent atrial fibrillation, the Hybrid Maze/Ablation (also called the Hybrid Convergent Procedure) combines the complementary efforts of both the cardiothoracic surgeon and the cardiac electrophysiologist. The surgeon works on the outside the heart and the EP on the inside of the heart to eliminate the Atrial Fibrillation signals.

In this video, two cardiac EPs and a cardiothoracic surgeon describe the advantages, safety and effectiveness of the Hybrid approach and who is a good candidate. Includes animation and on-camera interviews.

Published by Tenet Heart & Vascular Network. Length 4:30. 

YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click an icon to select.

If you find any errors on this page, email us. Y Last updated: Tuesday, July 17, 2018

Return to Instructional A-Fib Videos and Animations

A Tale of Two Ablations and Why All EPs Are Not Equal

I just received an email and O.R. (Operating Room) reports from Louis who in 2014 had a successful catheter ablation by Dr. David Wilber at Loyola in Chicago. Dr. Wilber is nationally known for both his ablation skills and experience, as well as for his research.

First Ablation with Dr. David Wilber

Dr. Wilbur’s ablation of Louis was textbook. Louis’ A-Fib terminated during his ablation procedure, which is considered the ideal outcome.

But Dr. Wilber didn’t stop there.

Dr. Wilber didn’t stop there; he found A-Fib signals coming from the Superior Vena Cava (SVC).

He used isoproterenol (IV medication) to try to induce non-PV triggers and found A-Fib signals coming from the Superior Vena Cava (SVC). He isolated the SVC and could no longer induce any arrhythmias in Louis. (Some EPs would not work that hard, and would have trouble finding and ablating non-PV triggers.)

Relocation, Then Second Ablation―Failure!

But later Louis did develop A-Fib/Flutter again. He had relocated to a distant state so he selected a second EP and had a second ablation there. This ablation was a failure.

After touching up the right pulmonary veins (PVs), the second EP used adenosine and pacing to try to induce arrhythmia signals. He induced Flutter and isolated the right atrium by making a cavo-tricuspid isthmus line. He documented bidirectional block in the right atrium, but Louis still had Flutter.

The second EP didn’t map and track down the flutter.

Rather than map and track down the source of the Flutter, the EP simply Electrocardioverted Louis and stopped the ablation at that point. Then he put Louis on the dreaded antiarrhythmic drug amiodarone.

Still in Flutter―Amiodarone Side Effects

But after the second ablation, Louis still had A-Fib/Flutter.

On amiodarone, Louis developed the symptoms of loss of weight, thinning hair, extreme dry mouth, increased hand tremors, etc. Louis was taken off of amiodarone and is doing better. But he is still bothered by Flutter. See Amiodarone Effective but Toxic.

I’m working with Louis to get him to a “master” EP, a highly skilled EP with a high success rate with difficult A-Fib cases.

What Went Wrong with Louis’ Second Ablation?

From what can be deduced from Louis’ O.R. (Operating Room) report, there seems to be no mention of checking for entrance and exit block after ablating Louis’ pulmonary veins.

As a “crutch”, he put Louis on amiodarone, the most effective but also the most toxic of the antiarrhythmic drugs.

The second EP did use adenosine and pacing and induced a Flutter circuit. He ablated the right atrium and made a cavo-tricuspid isthmus line to make sure no Flutter came from the right atrium. But Louis still had Flutter.

Instead of using any of today’s advanced mapping and isolation strategies, Louis’ EP simply Electrocardioverted him to restore him to sinus. Then he stopped the ablation.

As a “crutch”, he put Louis on amiodarone, the most effective but also the most toxic of the antiarrhythmic drugs.

All EPs are Not Equal―It May Take Work to Find the Right EP

I’m sorry to say, the second EP Louis went to is indeed listed in our directory of EPs. He has all the proper credentials and is a member of the Heart Rhythm Society. But all EPs are obviously not equal. (See my editorial, Huge Growth in Number of EPs Doing Catheter Ablations, But All EPs Are Not Equal.)

Don’t just go to the EP whose office is near you. Go to the best, most experienced EP you can reasonably find. I know it’s a lot of effort. But you have to work at finding the right EP for you.

Do your due diligence. Seek recommendations from your General Practitioner (GP) and from other A-Fib patients (see our Resources/Bulletin Boards for a list of online discussion groups).

If you know nurses or support staff who work in the cardiology field or in Electrophysiology (EP) labs, they can be great resources.

Don’t rely on a single online source when researching and selecting doctors. Be cautious of all doctor informational listings you find on web sites (yes, including this one).

Be prepared to travel if that’s what it takes.

Learn How to Select Your EP

On our page Finding the Right Doctor for You and your A-Fib, we take you step-by-step to finding the right EP for you and your treatment goals.

Catheter Ablation vs Surgery For A-Fib: Finally an Apples-to-Apples Comparison

Update July 27, 2018 Which is better from a patient’s perspective―Catheter Ablation or Surgery (Mini-Maze)? A new study compares the two head-to-head.

An article in Cardiac Rhythm News (no author), describes the SCALAF trial (Surgical vs. Catheter Ablation of paroxysmal and early persistent Atrial Fibrillation).

SCALAF Trial Design

The SCALAF study is the first randomized control trial of patients with symptomatic A-Fib. In a 1:1 ratio, 52 patients received either a catheter ablation or surgery as their first invasive procedure. Follow-up data in all patients was collected for 2 years using implantable loop recorders (Medtronic Reveal XT).

The measurement of success was freedom from A-Fib (atrial tachyarrhythmia) and off antiarrhythmic drugs with safety measured by procedure-related complications.

PV Isolation Direct Comparison: The catheter ablation arm only isolated the PVs without additional lesion sets. The surgical arm (Mini-Maze) only isolated the PVs (and removed the left atrial appendage).

Trial Results

Efficacy: Catheter ablation vs. surgical patients (60% vs. 27%) were free from A-Fib without drugs.

Efficacy: After 2 years, a significantly greater number of catheter ablation patients (60%) were free from A-Fib without having to take A-Fib drugs compared to a much smaller number of surgical patients (27%).

Safety: Surgery patients had a higher procedure-related complication rate (34.8% vs. 11.1%) and a higher rate of major complications (22% vs. 0.0%) compared to catheter ablation patients. That’s about 1-in-4 surgical patients who had significant complications.

Safety: Surgery patients had a higher procedure-related complication rate (34.8% vs. 11.1%).

Hospital Stay: Hospitalization was longer for surgical patients with an average hospital stay of nine (6–10) days compared to three (2–3) days for catheter ablation.

Trial Conclusions

The investigators concluded that catheter ablation of the PVs in the treatment of paroxysmal and early persistent A-Fib is safer and results in higher long-term arrhythmia free survival compared to surgical (Mini-Maze) PV isolation. Follow-up with continuous monitoring using implantable loop recorders was important for true and accurate outcomes.

What Patients Need to Know

Don’t Make Surgery Your First Choice: Following the 2014 Guidelines for the Management of Patients with Atrial Fibrillation, your first treatment option should not be surgery (Mini-Maze).

Catheter Ablation Higher Success and Safer: Though this was a small study, this trial showed that catheter ablation is safer with better long-term freedom from A-Fib (and without medication) when compared head-to-head with surgical Mini-Maze. Follow-up monitoring of each patient with an implantable loop recorder (for 24/7, 365 days for two years) produced unbiased, non-disputable results.

The 2011 FAST Trial: The SCALAF trial results might be compared to the 2011 FAST Trial sponsored by AtriCure, Inc. The FAST trial compared AtriCure’s own system for Mini-Maze surgery to catheter ablation. The results favoring surgery don’t hold up under close scrutiny. More important was the high complication rate of the surgical approach. For more, see Surgical Versus Catheter Ablation―Flawed Study.

SCALAF: Catheter ablation is safer with better long-term freedom from A-Fib (and without medication) when compared head-to-head with surgical Mini-Maze.
 The Bottom Line: We now have an unbiased clinical trial comparing catheter ablation with surgery.

According to the SCAFAL trial, catheter ablation has higher success for long-term freedom from A-Fib than the surgery approach. Just as important, data from both FAST and SCAFAL demonstrate that catheter ablation is much safer than surgery.

Update July 27, 2018: In response to this post about the SCAFAL trial, we received this statement from surgeon Dr. John H. Sirak who performs the “5 box surgery” for A-Fib. Especially relevant is his statement that surgical PVI alone tends to produce Flutter. (The FAST study did compare more complex surgeries to catheter ablation.)

“I must be direct and say this study is next to worthless. First, it isn’t clear how the cohorts compare in terms of AF chronicity. Surgical PVI should at least be no worse than percutaneous. PVI is the most foolproof step of a surgical maze. If the randomization were truly accurate, why was the surgical arm so much smaller? My suspicion is that the surgical arm had a significantly higher number of non-paroxysmal patients. And who were the orangutans operating with a 35% complication rate? Along the same lines, since surgical PVI alone is now widely known to be fluttergenic and thus contraindicated, no reputable surgeon would offer a patient such an outdated operation! This study is not only pathetically executed, but also has no relevance to current standard-of-care practice.” 
Resources for this article
• Surgical treatment of atrial fibrillation results in higher complication rates when compared to catheter ablation. Cardiac Rhythm News (no author). May 18, 2018, Issue 41, p. 9.

• Surgical or Catheter Ablation of Lone Atrial Fibrillation (AF) Patients (SCALAF). ClinicalTrials.gov Identifier: NCT00703157. Sponsor: Medtronic Bakken Research Center Note: Principal Investigators are NOT employed by the organization sponsoring the study. https://clinicaltrials.gov/ct2/show/results/NCT00703157.

• AHA/ACC/HRS 2014 Guideline for the Management of Patients With Atrial Fibrillation. Circulation. published online March 28, 2014, 4.2.1. Antiplatelet Agents, p 29.doi: 10.1161/CIR.0000000000000041 Last accessed Nov 23, 2014.URL: From http://content.onlinejacc.org/article.aspx?articleid=1854230

Catheter Ablation Compared to Amiodarone Drug Therapy in Heart Failure Patients with A-Fib

Background: I previously reported on the ground-breaking CASTLE-AF study published in 2018 which compared treatment with conventional antiarrhythmic drugs (both rate and rhythm control) versus treatment with catheter ablation. I recently came across another, similar study. While the 2016 AATAC study pre-dates the CASTLE-AF study, it also contributes to our understanding of treatment choices for heart failure patients with A-Fib.

Treating Patients with Both Heart Failure and A-Fib

Heart failure is very common in patients with A-Fib (estimated at 42%). These are very sick patients. For people with advanced heart failure, nearly 90% die within one year.

In patients with both conditions, a cardiologist’s first treatment is most often drug therapy with an antiarrhythmic drug. But is this an effective strategy? Is this really in the patient’s best interest? A 2016 study says NO!

AATAC stands for: Ablation vs Amiodarone for Treatment of Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted ICD/CRTD

AATAC: Catheter Ablation vs. Amiodarone Antiarrhythmic Drug Therapy

In the powerful AATAC multicenter worldwide randomized trial, catheter ablation was compared to drug treatment with amiodarone (the most effective but also the most toxic of the antiarrhythmic drugs).

The 203 enrolled patients had persistent A-Fib and heart failure with an Ejection Fraction of less than 40%. Patients also all had either a dual-chamber implantable cardioverter defibrillator or cardiac resynchronization therapy defibrillator.

All patients in the AATAC study were given optimal medical therapy for congestive heart failure such as ACE inhibitors, etc.

Patients were randomized to receive either a catheter ablation or drug treatment with amiodarone.

Note: The AATAC study should be read in conjunction with the more significant CASTLE-AF study which found similar results.

Group 1: Catheter Ablation

The first group received a catheter ablation of the pulmonary veins (PVI) along with roof lines and extensive ablations on the left atrial posterior wall; if non-PV potentials were found, the superior vena cava was isolated. At their discretion, EPs could ablate complex fractionated electrograms and non-PV triggers.

A ‘re-do procedure’ could be performed during the 3-month blanking period.

Group 2: Amiodarone (AMIO) Drug Treatment

The Amiodarone (AMIO) group was given 400 mg twice a day for 2 weeks followed by 400 mg each day for the next 2 weeks, then they were given a maintenance dose of AMIO 200 mg/day for the balance of the 24 month study period.

Study Follow-up and Results

All patients were followed for a minimum of 24 months. Recurrence was measured by the implantable devices with device interrogation at 3, 6, 12, and 24 months follow-up. Key findings at the end of the trial period include:

Recurrence: 70% of patients in the ablation group were recurrence and A-Fib free (after an average of 1.4 procedures) vs. only 34% of the Amiodarone (AMIO) group.

PVI with/without posterior wall isolation: Higher success was reported in patients undergoing PVI with posterior wall isolation compared to PVI alone (79% vs. 8%).

Amiodarone therapy was found to be significantly more likely to fail.

Cardioversion: During the 3-month blanking period 51% of the Amiodarone (AMIO) group needed cardioversion vs. 3% of the ablation group.

The unplanned hospitalization rate was 31% in the ablation group vs. 57% in the AMIO group. This is a 45% relative risk reduction of hospitalization.

A significantly lower mortality was observed in the ablation group: 8% vs. AMIO 18%.

Summary: Catheter Ablation Superior to Amiodarone Drug Therapy

Heart failure and A-Fib are common cardiac conditions that often coexist.

The AATAC study, the first randomized study of heart failure patients with persistent A-Fib, found that catheter ablation is superior to amiodarone drug therapy in achieving freedom from A-Fib long-term.

In addition, treatment with catheter ablation improved mortality in these patients, increased exercise capacity and Quality of Life (QofL) along with reduced unplanned hospitalizations.

Acknowledging My Bias
I admit to being biased against amiodarone drug therapy due to personal experience and from what others have shared. (For example, see Karen Muccino’s A-Fib story.) I am horrified that anyone would be put on such a high initial dosage of amiodarone as in this study. I would never participate in such a study. But obviously all doctors don’t share my concerns.
If a less potent (and less dangerous) antiarrhythmic drug had been used, it’s probable the study results would have been even more favorable for the ablation group.

What This Means to A-Fib Patients

These patients were in persistent A-Fib along with heart failure. These are some of the most difficult patients to make A-Fib free.

The EPs and A-Fib centers in this study were some of the best in the world. That there was a 70% success rate and no recurrences after 2 years is a testimony to the advanced mapping and ablation skills of these EPs. It’s remarkable how far catheter ablation strategies have improved over the years.

On the downside, not all EPs are equal. The single procedure success rate varied greatly from 29% to 61%. (See Huge Growth in Number of EPs Doing Catheter Ablations, But All EPs Are Not Equal.)

Catheter Ablation Group: Improved Ejection Fractions

Among the 203 enrolled patients, it’s not surprising that there were 26 deaths during this study. These were very sick patients with congestive heart failure and Ejection Fraction below 40%. (An EF below 50% indicates a weakened heart muscle that is no longer pumping efficiently; an EF in the normal range is 50% to 75%.)

The good news is that for many in the catheter ablation group, their ejection fraction was significantly improved and they were no longer in heart failure.

Catheter Ablation Outperforms Antiarrhythmic Drugs

We now have 2 studies which demonstrate that compared to antiarrhythmic drug therapy, catheter ablation lowers death rate among A-Fib patients (with heart failure), improves QofL and lets patients live longer and healthier lives. Other major benefits of ablation include reduced unplanned hospitalizations and increased exercise capacity.

Take-Away for A-Fib Patients

I think we can draw conclusions from the AATAC and the CASTLE AF studies that also apply to A-Fib patients (not in heart failure).

Rather than a life on antiarrhythmic drug therapy, the AATAC and CASTLE AF studies encourage A-Fib patients to seek a catheter ablation (including a second “re-do ablation”, if necessary.)

Bottom-line: Hard research data shows that a catheter ablation is the better choice over drug therapy. An ablation can rid you of your A-Fib symptoms, make you feel better, and let you live a healthier and longer life.

Don’t just live with A-Fib. Seek your cure.

 

Resources for this Article
Di Biase, L., et al. Ablation Versus Amiodarone for Treatment of Persistent Atrial Fibrillation in Patients With Congestive Heart Failure and an Implanted Device. Results From the AATAC Multicenter Randomized Trial. Circulation. 2016;133:1637-1644. March 30, 2016. http://circ.ahajournals.org/content/133/17/1637 DOI  https://doi.org/10.1161/circulationaha.115.019406

From My Mailbox: Catheter Ablation Complication Rate: Compared to What?

Frequently I get emails asking about the complication rate of catheter ablation.

I like the suggestion made by Dr. David Keane of St. Vincent’s University Hospital, Dublin Ireland. Complications from A-Fib ablation should be viewed in perspective, that is, compared to the alternative of a lifetime on antiarrhythmic drugs (AADs).

The following is based on his presentation from the 2014 Boston AF Symposium.

Meta-Analysis: RF Catheter Ablation vs. Antiarrhythmic Drugs

In what may be the first systematic literature review and meta-analysis of clinical studies of Radiofrequency Ablation (RFA) vs. Antiarrhythmic Drugs (AADs), the reviewers looked at studies from 1990 to 2007. [Note: RFA wasn’t in use until the mid-1990s.] Included were sixty-three RFA studies and 34 AAD studies.

RF Ablation: From 1990-2007, the single procedure success rate for Radiofrequency Ablation (RFA) without need of post-op Antiarrhythmic Drug (AAD) therapy was 57% [today’s success rates are in the 70%–85% range], multiple procedure success rates without post-op AADs were 71% [today’s success rates are closer to 90%], and the multiple procedure success rate with post-op AADs was 77%.

AAD Therapy: The success rate for AAD therapy alone was 52%.

Note: The meta-analysis included five AADs: amiodarone, dofetilide, sotalol, flecainide, and propafenone. Amiodarone was the most effective. [Amiodarone is the most toxic and dangerous of the five AADs and is usually prescribed only for short periods of time and under close supervision for bad side effects.]

Adverse Event: side effect or any undesirable experience associated with the use of a medical product in a patient. In the US, adverse events are reported to the FDA.

Side Effects Cause Patients to Stop Taking AADs: Because of adverse events (side effects), 10.4% of patients discontinued taking their AADs, 13.5% discontinued AADs because of treatment failure, and 4.2% just didn’t take the AADs.

The overall discontinuation rate of AADs was almost 30%.

Findings: Efficiency and Complications Rates

Based on the meta-analysis, reviewers found Radiofrequency Ablation (RFA) had a higher efficiency rate and a lower rate of complications than AAD Therapy.

Findings: Adverse Events Ablation vs AAD

As a point of reference, the complication rate of the common appendectomy is 18%.

This meta-analysis found adverse events for catheter ablation was 5% vs 30% for AAD studies.

More about AAD Therapy adverse events: The overall death rate for AAD therapy was 2.8% (i.e., sudden death 0.6%, treatment-related death 0.5%, non treatment-related death 1.3%). Other adverse events from AAD therapy were:

•  CV (cardiovascular) Events 3.7%
•  Bradycardia 1.9%
•  GI (Gastrointestinal problems) 6.5%
•  Neuropathy 5.0%
•  Thyroid Dysfunction 3.3%
•  Torsades 0.7%
•  Q-T prolongation 0.2%

Conclusions from Meta-Analysis

Most adverse events associated with antiarrhythmic drugs (AADs) are life altering and permanent. (For example, bradycardia requires a pacemaker.)

Whereas complications from catheter ablation are generally short term and not permanent. (For example, when tamponade is repaired, the heart usually returns to normal.)

While this meta-analysis covered 1990-2007, based on subsequent research the trends are continuing. In general, it appears it’s safer to have an ablation than to not have one while living a life-time on AAD therapy.

D. Keane MD

The Full Report: For the full summary of Dr. Keane’s 2014 Symposium presentation, see: Catheter Ablation Complications: In-depth Review and Comparison with Antiarrhythmic Drug Therapy.

What this Means to Patients

If you are age 70 or 80, antiarrhythmic drugs might be a realistic option.

But if you are younger, it’s inconceivable that you would spend the rest of your life taking AADs. In addition to not working well or losing their effectiveness over time, they can have bad, cumulative side effects as described above.

Today’s ‘Guidelines for the Management of Patients with Atrial Fibrillation’ reflect this fact and allow you to select a catheter ablation without having to spend time trying various antiarrhythmic drugs (while your A-Fib may be getting worse).

In general, research shows it’s safer to have an ablation than to not have one (and live a lifetime on AA drug therapy).

Resources for this Article
•  Deshmukh, A. et al. In-Hospital Complications Associated with Catheter Ablation of AF in US: 2000-2010. Analysis of 93,801 Procedures. Circulation. 2013;128:2104-2112. http://circ.ahajournals.org/content/128/19/2104.abstract

•  Haïssaguerre M. “Electrophysiological End Point for Catheter Ablation of Atrial Fibrillation Initiated From Multiple Pulmonary Venous Foci,” Circulation. 2000;101:p. 1409

•  Jais, P. “Ablation Therapy for Atrial Fibrillation: Past, Present and Future,” Cardiovascular Research, Vol. 54, Issue 2, May 2002, P. 343

•  Cappato R et al. “Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation.” Circulation: Arrhythmia and Electrophysiology. 2010: 3:32-38.

•  AHA/ACC/HRS. 2014 Guideline for the Management of Patients With Atrial Fibrillation: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014; 130: e199-e267 DOI: 10.1161/CIR.0000000000000041.

Story Update: Ashley Mogg, a 23-Year Old Jamaican, Now A-Fib Free!

I’ve seldom been so happy to write about an A-Fib success story (actually an update)! A story that had such a miserable beginning.

A-Fib at 17 and Started Losing Sight!

Eighteen months ago, I wrote a story about 21-year-old Ashley Mogg from Jamaica. Her A-Fib was horrible. Her first A-Fib attack came at age 17 when she had just stopped playing field hockey. Ashley wrote:

Ashley Mogg from Jamaica

“I was feeling extremely unfit. My heart rate sped up and my chest got tight. My throat felt like it was closing, and I was starving for a breath. Then the most frightening thing happened―I started losing my sight! Pitch black was all I saw. I could hear my friend talking to me through it. It was so scary for me.”

Her doctor told her losing sight was a symptom of pre-faint or pre-syncope. Her stress test showed a heart rate that at times went up to 270 bpm.

Clinical Depression Sets In

To make matters worse, her cousin died suddenly. Then Ashley had to have an appendectomy which revealed a low grade Neuroendocrine tumor (cancer). Coupled with her dreadful A-Fib symptoms, she became extremely depressed and anxious (clinical depression is all too common in new A-Fib patients). She also suffered weight loss and became very thin.

No A-Fib Centers in Jamaica

Unfortunately, when I researched resources for her I couldn’t find any A-Fib centers or Electrophysiologists in Jamaica. It was heart breaking that such a young woman had such a debilitating case of A-Fib, and I couldn’t find anyone near her to take care of her.

November 2016: Asking for Funding and Help for Ashley

What I did was publish her story on A-Fib.com and ask for donations to pay for her to see an EP in the U.S. (Read Jamaican Woman, 21, Living in A-Fib with Meager Treatment)

Dr. Natale confirmed that there was no EP lab in Jamaica and would try to find money from the A-Fib industry to help Ashley.

In addition, I sent Ashley’s story to Dr. Andrea Natale, a master EP with a world-wide reputation. A colleague of his, Dr. Francesco Santoni, emailed me that he tries to help arrhythmia patients in Jamaica through the Rotary Club and another foundation. Travis Smith, President of the Rotary Club of Downtown Kingston, Jamaica championed Ashley’s cause.

Dr. Natale suggested we work with Dr. Lisa Hurlock in Kingston, Jamaica at the University of the West Indies who could follow her arrhythmia. She met with Ashley and her mother, Loretta. Dr. Natale confirmed that there was no EP lab in Jamaica. He said he would try to find money from the A-Fib industry to help Ashley.

Dr. Natale’s Heroic Efforts to Help Ashley―Biosense Webster Donation

Dr Andrea Natale

Dr Andrea Natale

Dr. Natale obtained a donation from Biosense Webster (Johnson & Johnson) to cover travel expenses for Ashley and her mother to St. David’s Medical Center, Austin, TX including lodging, food and transportation. He also arranged for St. David’s to waive all fees for Ashley’s catheter ablation. The Texas Cardiac Arrhythmia Foundation accepted donations to help Ashley. Barbara Thomas and Amy Dixon coordinated everything at St. David’s.

(I probably don’t have all the names of everyone involved in helping Ashley. Please email me if I haven’t mentioned you or someone else who helped.)

Ashley, mom Loretta and hospital staff

July 2017: Ashley Has Her Ablation & is A-Fib Free!

On July 19, 2017, Ashley had her ablation. She is now A-Fib free. It was performed by Dr. Natale and his team at St. David’s Medical Center, Austin, TX. Since then, she has written that she is doing fine and has started college in Jamaica (she wants to go to medical school).

In an excerpt from her personal story (written before her ablation became a reality), Ashley shared these lessons learned:

“Educate Yourself―Find the Best Doctors Available. If you live in a country like myself where there are very few Electrophysiologists or heart rhythm specialists, find a reliable cardiologist as well as a general doctor who know your history. Do maximum research on your own and with your doctor and health care professionals. Stay informed.
…Stay positive…You are NOT ALONE!”

Remarkable for a 21-year old who has had a rapid beating heart since childhood.

March 2018 Update: Email from Ashley’s Mother

Loretta Mogg, Ashley’s mother recently wrote me:

Ashley and her mom, Loretta

“I am Loretta Mogg, the mother of Ashley Mogg. I want to express a heartfelt thanks to you for posting my daughter’s story and seeking help for her.
Just a little update. After nearly a year since her ablation, she is back in University and doing well. She is still determined to become a doctor.
Thank you for allowing God to use your own experience to change the life of another. Blessings to you and your family.”

Thanks to All, Especially to Dr. Natale

It’s impossible to adequately thank everyone, especially Dr. Natale, who helped Ashley in her incredibly difficult A-Fib journey.

I don’t know if we’ll ever understand how a young 17-year-old woman could develop such awful A-Fib symptoms. (Perhaps it related to her cancerous appendectomy.)

Faith and a Purposeful Life

Kudos to Ashley for not giving up with all she went through! She’s an incredible young woman. She had to grow up fast. She became a woman of faith with a purposeful life. In her own words, “It takes prayers and positive thinking to keep living with peace of mind.”

Be Inspired: You, too, Can Help Others With A-Fib

One-to-One, our A-Fib Support Volunteers are just an email away at A-Fib.comOne way to live a life of faith and purpose is to help others suffering with Atrial Fibrillation. Join our Prayer and Positive Thoughts group or our A-Fib Support Volunteers group.

Offering hope: Having someone you can turn to for advice, emotional support, and a sense of hope that you can be cured, may bring A-Fib patients (and their families) peace of mind.

We are blessed to have many generous people who have volunteered to help others get through their A-Fib ordeal (not all are ‘cured’). To learn more and how you can join the effort, see my article: ‘Want to Become a A-Fib Support Volunteer?

We’ve Got Answers: Browse Our Q&As About Catheter Ablation for Atrial Fibrillation

After reading our page about Catheter Ablation: Pulmonary Vein Ablation, you may have many questions. At A-Fib.com, we have answered thousands of questions from A-Fib patients—many of the same questions you may have.

In the realm of catheter ablation, the range of issues and questions can be staggering. Topics including RF energy vs Cryo, enlarged heart and heart failure, PV vs non-PV potentials/triggers, recurrences, O.R. Reports and many more.

At A-Fib.com, we provide answers. Here are a few of the questions we answer in FAQ: Catheter Ablation Procedures:

Steve S. Ryan observing ablation by Dr. Sidney Peykar, Cardiac Arrhythmia Institute

Radiation exposure:How dangerous is the fluoroscopy radiation during an ablation? I’m worried about radiation exposure.”

Blanking Period:How long before you know a Pulmonary Vein Ablation procedure is a success?

Clots/Blood Thinners: “I was told that I will have to take an anticoagulant for about 2-3 months after my ablation. Afterwards shouldn’t there be even less need for a prescription anticoagulant rather than more?”

Non-PV Triggers:Are there other areas besides the pulmonary veins with the potential to turn into A-Fib hot spots?

 A-Fib cure?I’ve read that an ablation only treats A-Fib symptoms, that it isn’t a ‘cure.

Browse our Q&A: Catheter Ablation: Pulmonary Vein Ablation, CyroBalloon Ablation

Additional topics we cover: the heart’s blood pumping capacity, the age range for a successful ablation, time length of a typical ablation, developing a clot during an ablation, resuming ‘normal’ exercise after a PV, who’s a candidate for a Pulmonary Vein Ablation, and more.

Go to FAQ About A-Fib Treatments Options: Catheter Ablation Procedures to browse all our posted questions and ‘click’ on any question to jump to the answer.

More Categories of Question & Answers

For all our Q & A lists, go to our page Frequently Asked Questions (FAQs) by Patients with Atrial Fibrillation.

At Medical Centers: Why to Always Ask for a Specific EP

In talking with A-Fib patients, I’ve found a disturbing trend when they seek an Electrophysiologist (EP) at a medical center when they don’t have the name of a specific doctor.

Often the medical center’s office will assign the newest and/or least experienced EP on staff.

Not good. Instead, you want an experienced EP with a high success rate at getting A-Fib patients back into normal rhythm. (You deserve nothing less.)

Your Search for the Right EP

First, seek recommendations from your General Practitioner (GP) or cardiologist. If you know nurses or staff who work in the cardiology field, they can be great resources. Ask for referrals from other A-Fib patients.

Begin your own research with our page, Find the Right Doctor for You. Then check our Directory of Doctors Treating A-Fib.

All EPs Are Not Equal

After you’ve done your research, you’ll have a list of EPs you know are more experienced in getting A-Fib patients back into normal sinus rhythm. (For example, someone with the initials FHRS after his name, and/or a ‘Castle Connolly Top Doctor’).

Then, you can contact a medical center and ask for a particular EP.

Especially when you are seeking an ablation, all EPs are not equal. Selecting the right EP isn’t like getting a haircut at SuperCuts where any stylist will do.

Left Atrial Appendage (LAA): An Under-Recognized Trigger Site of Atrial Fibrillation

Recurrence of A-Fib after an ablation is very disappointing and frustrating both for patients and for EPs performing the ablation.

A link to the source of A-Fib recurrence may have been found. A study by Dr. Di Biase and his colleagues established that the LAA is responsible for a great deal of A-Fib recurrence.

Research: LAA Responsible for 27% of Recurrences

The multi-center study enrolled patients at leading medical centers in Austin, Texas, San Francisco and Palo Alto, Calif, Rome and Venice, Italy, Cleveland and Akron, Ohio.

In the study of 987 patients undergoing redo catheter ablations, 266 (27%) showed a prevalence of A-Fib triggers firing from the LAA.

In 32+% of these 266 patients, the LAA was the only source of arrhythmia signals.

Trial Design of LAA for Recurrences

The 266 patients were divided into three groups with different treatments. Each group was followed for 12+ months with these results:

  • Group 1. The LAA was not ablated (isolated); 74% of this group had recurrences of A-Fib.
  • Group 2. The LAA was ablated with focal lesions. 68% of this group had recurrences of A-Fib.
  • Group 3. The LAA was ablated by a circular catheter at the ostium of the LAA. 15% of this group had recurrences of A-Fib.

Trial Findings: LAA Responsible for Much A-FibLeft Atrial Appendage heart illustration

While this study was limited, as it only looked at redo ablations and recurrences, it’s significant. The patients (Group 3) who were ablated by a circular catheter at the ostium of the LAA, had a recurrence rate of only 15%!

Compared to 68% and 74%, this is a major, significant reduction in recurrences. This is great news for A-Fib patients undergoing a catheter ablation.

Trial results indicate that the LAA is responsible for a great deal of arrhythmia signals, probably more than any other area of the heart.

A-Fib Ablations: Check LAA for Non-PV Signals

Many EPs today aren’t aware of the importance of the LAA as a source of A-Fib signals and never even look at the LAA when doing an ablation. In the words of the study’s authors, “the LAA is an underestimated site of initiation of atrial fibrillation.

It’s good news that an increasing number of EPs after performing a PVI, then as their second step, map and ablate the LAA. This is especially in cases of persistent A-Fib and those with non-PV triggers. After the PVs are isolated, the LAA should be the next place to look. (Make sure your EP is one those who check the LAA!)

What This Means to Ablation Patients

This research is important not just for patients undergoing a redo catheter ablation but for any A-Fib patient seeking a catheter ablation.

Important when selecting your EP: When having a catheter ablation, no matter what kind of A-Fib you have, make sure your EP knows how, is experienced at, and routinely maps and ablates the LAA.

This may produce a more successful ablation and save you from a recurrence of A-Fib.

To learn more about the Left Atrial Appendage, see my article, The Role of the Left Atrial Appendage (LAA) & Removal Issues.

Resources for this Article
Di Biase et al. Left Atrial Appendage: An Underrecognized Trigger Site of Atrial Fibrillation. Circulation. 2010;122:109-118. http://circ.ahajournals.org/content/122/2/109. https://doi.org/10.1161/circulationaha.109.928903

At 55, A-Fib After Underwater Hockey, Then 2 Failed Ablations & a 3rd Using the ECGI Vest

By Martin Johnson, Champaign, IL. March 2018
With a post-script by Dr. Phillip Cuculich, Barnes-Jewish/Washington Un.

Martin Johnson

“My first A-Fib attack that I noticed, occurred in 2003 when I was 55 years old during a game of underwater hockey, an extreme sport requiring swimming under water while pushing a lead puck from one end of the pool to the other.

At first, I thought “well I did just swim 25 yards under water as fast as I could, so maybe this is just normal”. It lasted about 20 seconds.

The attacks quickly increased their duration to a couple hours each over the next couple months. I was forced to give up the game I’d been playing since age 37. I switched sports to softball, but that soon became impossible too, as I got an A-Fib attack every single game (but oddly, never at a practice).

A-Fib Progresses―Attack Just Sitting at Desk

For the first couple of years I only got attacks after physical exertion. As time went on, less and less exertion was required to trigger one.

I had my first attack without any kind of physical exertion while sitting at my desk at work. It scared me enough to see the local EP who recommended that I get an ablation. I thought that was too aggressive and instead started to try various drugs.

“My EP’s prognosis was―’ever more often, ever longer attacks until I would be in permanent A-Fib’”.

After going through 6 different drugs, most of which had no effect, one of which almost killed me and another that modified my attacks, I had no net improvement. My EP’s prognosis was “ever more often, ever longer attacks until I would be in permanent A-Fib”.

By 2010, I was getting approximately 24-hour long attacks approximately every four days plus occasional attacks triggered by physical exertion.

My First Ablation

I had my first RF ablation in July of 2010. I asked the EP if I should be in my natural A-Fib before the ablation, so that he could locate the problem cells. He said ‘no’. Instead, he induced A-Fib chemically. His approach was to isolate the PVs and draw several other lines in the left atrium. He then ablated the cells that he could detect taking part in the A-Fib that he induced.

He successfully got my heart back into Sinus Rhythm (SR), and was unable to further induce A-Fib. His OR report says that he expected this to have been a cure. (An O.R. [Operating Room] report describes what the EP did during the ablation.)

Two hours after the ablation, I was in A-Fib again.

In A-Fib Again―Leads to a Second Ablation

My A-Fib attack timing continued without letup— 24-hour-long attacks every 4 days. I agreed to a second ablation 6 months later.

“Two hours after the ablation, I was in A-Fib again.”

The OR Report for the second ablation was essentially the same as the first, and so were the results. After both ablations, I acquired new arrhythmias that annoyed me even while not in A-Fib. After about 6 months, the new arrhythmias abated, and my A-Fib pattern changed to 24 hours every 7 days—a small but welcome improvement.

Over the next five years, the attacks became longer and more frequent— by Jan 2016, I had 45 hours of A-Fib every 7 days.

Third Ablation? I Needed an Edge

Still I was not optimistic about a third ablation considering my previous poor results.

Medtronic ECGI vest

I decided I needed an edge—something that might be able to find whatever oddball A-Fib cause made me difficult to cure. The one thing that stuck out in my reading was the Medtronic ECGI vest used in Bordeaux, France by Dr Haissaguerre and others. [See How ECGI (Non-Invasive Electrocardiographic Imaging) Works.]

The 256 electrode ECGI vest enabled the graphic display of the electrical activity of the heart passively and totally non-invasively. Unfortunately, Dr Haissaguerre’s office would not respond to any of my attempts to contact him. And I learned that the FDA would not permit the use of the vest in the US as part of an ablation procedure.

Travel to St. Louis Where the ECGI Vest Was Invented

It seemed that all doors to the vest were shut. After some investigation, I discovered that the vest had actually been invented in the US at Washington Un. in St. Louis, MO. In January 2016

“I volunteered for a study…that might help me get use of the vest in spite of the FDA.”

I called up the inventor’s lab to get as much information as I could. I volunteered for a study with the hope of making connections that might someday help me get use of the vest in spite of the FDA.

In January 2017, I went to St Louis and got a CT scan and a vest recording for the study I had volunteered for. While there, I noticed a Dr. Cuculich come into the lab to borrow a vest. I immediately thought, this is the guy I need to keep track of.

FDA Approves Medtronic ECGI Vest―My New Hope!

Then the next month, Feb 2017, the FDA approved a commercial version of the vest made by Medtronic for use with A-Fib ablation.

By this time, I was having 48 hour attacks every 4 days. I called Medtronic to get a list of who in the US had bought the vest and who had any experience using it. To my relief, Barnes-Jewish Hospital in St Louis was one of only four buyers, and Dr Cuculich already had experience using the vest on non-A-Fib applications.

Now that I had located a possible vest practitioner, I still had to resolve other concerns. In particular, even Dr Haissaguerre in France didn’t use the vest on paroxysmal A-Fibbers. He only used the vest on patients with permanent A-Fib. I don’t know why. I was convinced that being in my natural A-Fib and not in chemically induced A-Fib, was essential to find the real causes. I also knew that I could put myself into A-Fib by physical exertion.

BisenseWebster Smart Catheter illustrations

Example of Contact force catheter (Biosense Webster)

Another Technology Edge: The Contact Force Catheter

Another technology that seemed important was the technique of dragging the catheter in order to burn a continuous line, rather than trying to burn individual dots. To help with this, a contact force catheter also seemed necessary. I first became aware of this due to a paper written by Dr Natale of Austin, TX. (see Resources below for article.)

A Concern: I Don’t Want to Lose My LAA

Another concern of mine was the insistence by some EPs to electrically isolate the Left Atrial Appendage (LAA).

“…in my mind…if the ablation worked, there would be no advantage to having closed off the LAA.”

During A-Fib, the blood in the LAA becomes stagnant, permitting the formation of clots.

But cutting off incompletely understood parts of one’s heart seemed exceedingly rash. Also, if the ablation worked, there would be no advantage to having closed off the LAA. So, closing off the LAA was just preparing for a failed ablation, in my mind.

About the Left Atrial Appendage (LAA)

What little is known about the LAA includes the fact that it is the source of heart stem cells needed for repair of the heart.

It was once thought that the heart cells you died with were the same ones you were born with. The latest belief is that about 40% of your heart is replaced during a full life.

This is a function I did not want to lose.

The LAA is also the source of a hormone which helps control blood pressure. The LAA also has a pumping function in parallel with the Left Atrium. And electrically isolating the LAA can often significantly reduce the contractile function of the LAA, thus making it a source of clots even when the heart is not in A-Fib.

Consulting Dr. Phillip Cuculich at Barnes-Jewish/Washington Un.

I called up Barnes-Jewish to inquire about my above listed concerns. Dr Cuculich called back and assured me that he was able and willing to meet all these requests:

1) Use the ECGI vest during ablation even though I’m paroxysmal;
2) To expect me to be in my organic A-Fib;
3) After getting me into Normal Sinus Rhythm, chemical induction of A-Fib was OK to track down more problems;
4) Use a contact force catheter and draw continuous lines rather than dots;
5) Leave my LAA electrically and physically intact.

Third Ablation―Running Up Flights of Stairs

The night before the scheduled ablation, I ran up and down a flight of stairs ten times which put me in my organic A-Fib in preparation for the following morning’s ablation.

On Nov 2, 2017, two Medtronic technicians fitted the 3-piece vest onto my torso. The ablation procedure took 5 hours—a lot longer than Dr Cuculich was planning on.

I woke up in NSR! The doctor noted that an A-Fib source in a pulmonary vein was active, but was already successfully being blocked by the ablation.

In Normal Sinus, But Short Bursts of A-Fib

Since the ablation 3.5 months ago, I have had about 15 A-Fib attacks totaling about 7 hours of A-Fib. [It’s not uncommon for A-Fib to reoccur during the three month ‘blanking period’ following an ablation.]

I believe every attack was triggered by drinking cold water. It took me a while to figure that out. I have not had an attack for the last month, during which I was able to remember ‘no cold water’!

Lessons Learned

For future reference: I read that Dr Cuculich was the lead investigator in a study of a totally non-invasive ablation procedure that uses the Medtronic vest to find the problems and ‘multi-beam focused radiation’ to ablate the errant heart cells.

I’m hoping that if my A-Fib comes back, that the FDA won’t have been as slow permitting this new method, as they were with the vest (see Resources below for link).

In light of my experience, I would recommend that no one get an ablation without the advantage of the Medtronic ECGI vest. Without it, the EP is only guessing.

Using canonical ablation patterns that might have worked on some group of A-Fibbers, or using the old fashioned way of dragging a sensing catheter along the entire inner surface of a beating heart looking for electrical anomalies, is laughable to me.

It’s no wonder that my first EP couldn’t find the A-Fib sources inside my coronary sinus and right atrium. I welcome your emails.”

Marty Johnson
martyj1949(at)yahoo.com

Comments from Dr. Phillip Cuculic

Electrophysiologist Phillip Cuculich, MD

Phillip Cuculich, MD

“Thank you, Steve, for the chance to reply [to Martin’s A-Fib story]. And thank you, Martin, for sharing your story with the world. Brave patients and advocates like you are a powerful combination in today’s world of medicine.

Our understanding of any arrhythmia mechanism falls into two bins: the initiating event (triggers) and the sustaining circuit.

Over the past several decades, invasive procedures have identified common locations that harbor AF triggers, which is how pulmonary vein isolation has been an effective procedure to control AF for most patients. In general, we as a field have struggled in identifying reproducible non-PV triggers and the sustaining AF circuits.

One reason for our struggle is the tools with which we measure. A second reason is that each person’s AF is different, so the findings of one group of patients is not easily applicable to an individual patient that I meet for consultation.

Martin’s experience with noninvasive ECGI is a wonderful example of personalized medicine: treating an individual patient’s AF physiology. Credit for the development and clinical validation of this technology goes to the scientists, clinicians and industry development teams which include Dr. Yoram Rudy (Washington University), the amazing scientists who graduated from his lab, the intrepid clinical and investigational teams in Bordeaux, France, and the hard-working developers at CardioInsight and Medtronic.

Presently, thoughtful application of noninvasive ECGI is getting us closer to personalized AF treatment. Further development, testing, and refinement of the ECGI system is underway. While there is much more to accomplish in understanding the critical components of each individual patient’s AF, one cannot help but hear the hope dripping from the story that Martin shared.”

Editor’s Comments
I admire Martin’s tenacity in seeking his A-Fib cure after two failed catheter ablations. He educated himself about his disease and its treatments. Then he sought out an EP who would meet his needs, even drawing up a five-point check list to discuss before his third ablation. Well done, Martin!
Martin’s O.R. Report: Dr. Cuculich found all Martin’s PV’s were still not isolated or had re-connected. After his two previous ablations, all Martin’s PVs had connected/re-connected. Dr. Cuculich also found many gaps in Martin’s previous roof and mitral isthmus ablation lines.
ECGI Vest Found Hard-To-Map Drivers: The Medtronic ECGI Vest mapping system found Non-PV driver areas in Martin’s heart that easily could have escaped notice with routine mapping systems, areas such as the Coronary Sinus, Left Superior Pulmonary Vein and lateral Right Atrium.
During Dr. Cuculich’s ablation, Martin’s A-Fib/Flutter terminated when his Coronary Sinus was effectively ablated and isolated. This is considered the best outcome of an ablation. Most EPs would have stopped at this point. But because the Medtronic ECGI vest had indicated there were more A-Fib signal sources not yet ablated, Dr. Cuculich ablated those areas as well.
Medtronic ECGI Vest Very Effective! Martin’s A-Fib was a difficult case after two failed ablations. Instead of the usually 2-3-hour ablation, Martin’s took 5 hours, probably because the previous 2 ablation lesions made the third ablation more complicated.
The Medtronic ECGI Vest seems to be a major advance and improvement in the treatment of A-Fib. It certainly worked in Martin’s case. But at this time, few centers in the U.S. are using it and are only beginning to develop significant experience. This is because Medtronic wants the system to work as best as possible before making it more widely available.
What this means to patients: If you have persistent A-Fib or would be considered a potentially difficult case, try to find a center or EP with experience using the Medtronic ECGI Vest (even though you may have to travel.) It seems to be the next major advance and best mapping/ablation system on the market.

References for this Article

Kolata, G. A ‘Game Changer’ for Patients With Irregular Heart Rhythm. The NewYorkTimes.com, Dec. 13, 2017. https://www.nytimes.com/2017/12/13/health/heartbeat-tachycardia-radiation.html

Cuculich, P. S., et al. Noninvasive Cardiac Radiation for Ablation of Ventricular Tachycardia. December 14, 2017. N Engl J Med 2017; 377:2325-2336. DOI: 10.1056/NEJMoa1613773. http://www.nejm.org/doi/full/10.1056/NEJMoa1613773

Ryan, S. The New Era of Catheter Ablation Technology: Force Sensing Catheters. A-Fib.com http://a-fib.com/moussa-mansour-md-force-sensing-catheters-2014-bafs/

Ryan, S. The Role of the Left Atrial Appendage (LAA) & Removal Issues. A-Fib.com http://a-fib.com/left-atrial-appendage-role-and-removal-issues/

Natale, A., et al. Paroxysmal AF Catheter Ablation With a Contact Force Sensing Catheter: Results of the Prospective, Multicenter SMART-AF Trial. Journal of the American College of Cardiology, 2014. ISSN: 1558-3597, Vol: 64, Issue: 7, Page: 647-56. https://doi.org/10.1016/j.jacc.2014.04.072

Learn about sharing your A-Fib story

Return to: Personal A-Fib Stories

If you find any errors on this page, email us. Y Last updated: Friday, June 22, 2018

2018 AF Symposium: Kiss of Death for FIRM Mapping? The REAFFIRM Trial

In a late-breaking presentation, the interim results of the REAFFIRM trial were presented by Dr. John Hummel from the Ohio State University Wexner Medical Center.

Focal impulse and rotor modulation (FIRM)

FIRM stands for Focal impulse and rotor modulation (FIRM) and is used for mapping electrical signals of the heart.

The trial was intended to assess the safety and effectiveness of FIRM mapping used with conventional ablation (including PVI) versus a standard PVI procedure for the treatment of persistent atrial fibrillation.

REAFFIRM Trial Design

In a prospective multi-center trial, 350 patients with persistent or long-standing persistent A-Fib who had not had a previous ablation were randomized in a 1:1 fashion. The trial was designed to compare FIRM mapping used with standard catheter ablation (including PVI) versus PVI without use of FIRM mapping.

The non-FIRM ablation control group included…Continue reading this report->

Review All My Reports

To browse all my 2018 reports, go to my 2018 AF Symposium page (or use the link in the left menu column).

My 2018 reports

2018 AF Symposium My Last 2 Live Procedures Reports

The Left Atrial Appendage was a popular topic at the 2018 AF Symposium. My last live case reports present two more ways for isolating the Left Atrial Appendage, one an occlusion device and the other using a CryoBalloon catheter.

Amplatzer Anulet

Installing an Amplatzer™ Amulet™ LAA Occluder

Dr. Claudio Tondo from Milan, Italy, demonstrated an LAA closure by inserting the Amplatzer Amulet LAA closure device. Because of the patient’s history of major bleeding, Dr. Tondo decided to close off her LAA first while postponing a PVI until later. (In Europe, a LAA occluder can be inserted at the same time as a catheter ablation). (See also, Installing a Coherex WaveCrest LAA Occlusion Device.)

The Amplatzer has two lips which close over both the outside and the inside of the LAA―like a sandwich…Continue reading this report->

CryoBalloon catheter

CryoBalloon catheter

CryoBalloon Catheter for Isolation of the LAA

To isolate the Non-PV triggers originating in the patient’s Left Atrial Appendage, Dr. Knight used a CryoBalloon catheter in order to penetrate deeper into the LAA tissue.

Using the CryoBalloon Catheter for this procedure is an “off-label use”, i.e., a new use not described in the FDA approved device labeling. (Also see, Isolating the Left Atrial Appendage using RF Energy) Dr. Knight used a 28mm CryoBalloon catheter… Continue reading this report>

Read My Other Live Case Reports

To browse all my 2018 reports, go to my 2018 AF Symposium page (or use the link in the left menu column).

My 2018 reports: more to come

2018 AF Symposium: REAFFIRM Trial—Kiss of Death for FIRM Mapping?

by Steve S. Ryan, PhD

John Hummel MD

In a late-breaking presentation, the interim results of REAFFIRM were presented by Dr. John Hummel from the Ohio State University Wexner Medical Center.

Focal impulse and rotor modulation (FIRM)

Note: REAFFIRM stands for “Randomized Evaluation of Atrial Fibrillation Treatment with Focal Impulse and Rotor Modulation Guided Procedures” (REAFFIRM).
FIRM stands for Focal impulse and rotor modulation (FIRM) and is used for mapping electrical signals of the heart.

The trial was intended to assess the safety and effectiveness of FIRM mapping used with conventional ablation (including PVI) versus a standard PVI procedure for the treatment of persistent atrial fibrillation.

REAFFIRM Trial Design

In a prospective multi-center trial, 350 patients with persistent or long-standing persistent A-Fib who had not had a previous ablation were randomized in a 1:1 fashion. The trial was designed to compare FIRM mapping used with standard catheter ablation (including PVI) versus PVI without use of FIRM mapping.

The non-FIRM ablation control group included CTI (Cavo Tricuspid Isthmus Ablation for atrial flutter) and extra non-PV trigger ablations. Irrigated catheters were used in all cases, but not all used contact force sensing catheters.

Patients were monitored for 12 months with Holter and implantable monitors. The patients were primarily white males 65+ years old. There were no significant differences in the two groups of patients.

Trial Results: No Significant Difference in FIRM+PVI vs. PVI Alone

Prediction: It was anticipated that the control arm (PVI alone) would have a freedom from A-Fib success rate of 40% versus the treatment arm (FIRM+ PVI) would have a success rate of 75%.

Actual: At 12 months the success rate of the treatment (FIRM+ PVI) was 78%, while the control group with PVI alone had a success rate of 70%. This was a non-significant difference (not what the researchers had expected).

Translation: The control arm of the trial (PVI alone) did much better than anticipated. The researchers are trying now to look more closely at the details of the non-FIRM trial to identify why it did so well.

What this Trial Means for Patients

The REAFFIRM trial was a well designed study which showed that FIRM is not significantly better that a standard well-performed PVI ablation.
This is not the first study to call into question the effectiveness of the FIRM system. Critical Analysis of the FIRM Mapping System (2015) and More FIRM Research: Mapping System Falls Short (Again) (2016).
Unless and until the smoke clears and we have further research, the FIRM system probably won’t be an effective player long-term in the world of A-Fib ablation.
Bottom line: Don’t go out of your way to find a center or EP using the FIRM mapping system.

If you find any errors on this page, email us. Y Last updated: Wednesday, February 28, 2018

Back to 2018 AF Symposium Reports

2018 AF Symposium Live Procedures: Four New Reports

The live cases are what I like best about attending the AF Symposiums. From world-wide locations via streaming video, we join doctors in their various EP labs while a procedure is underway. The EPs address the symposium audience directly, often fielding questions.

AF Symposium 5-floor-to-ceiling video monitors at the Hyatt Regency Orlando

AF Symposium 5-floor-to-ceiling video monitors

We watch these live procedures on floor-to-ceiling high monitor screens. You feel like you are actually in the EP lab with these doctors.

My Favorite and My Most Difficult

While I like live cases the best, they are also my biggest challenge when it comes to writing quality reports.

My difficulty is they are often dealing with devices or treatments I have never heard of before. I take notes as best I can while trying to understand and follow the new concepts and treatments. Happily, I can often send my reports to the doctors involved so they can correct any mistakes and misconceptions.

Four New Live Case Reports

EP and attendee during live case

I’ve posted my first four reports on the live cases (2 more to come). From Belgium to Boston and Texas to Prague, all relate to performing catheter ablations: a device to protect the esophagus, two related to the Left Atrial Appendage (LAA), and a clinical trial of mapping software to better identifying rotors and drivers.

The DV8 Retractor: an Esophageal Deviation Tool from Manual Surgical Sciences with Drs. Kevin Heist, Conor Barrett and Moussa Mansour, all from Massachusetts General in Boston, MA

LAA ClosureInstalling a Coherex WaveCrest LAA Occlusion Device with Dr. Tom De Potter from Aalst, Belgium

RADAR―A Software Breakthrough in Mapping and Identifying A-Fib Rotors and Drivers? with Dr. Petr Neuzil from Prague, Czech Republic

Isolating the Left Atrial Appendage using RF Energy with Dr. Rodney Horton, Texas Cardiac Arrhythmia Institute, Austin, TX

Just Like Being There

These live cases are probably the closest symposium attendees can come to visiting all of these various global locations and observing these world-class master electrophysiologists and their teams.

For many attendees the live cases are often the most innovative and rewarding of the AF Symposium presentations.

Looking for all my 2018 reports?
Go to my 2018 AF Symposium page (link in the left menu column).

My 2018 reports: more to come

2018 AF Symposium Live Case: Isolating the Left Atrial Appendage using RF Energy

by Steve S. Ryan, PhD.

Rodney Horton MD

Dr. Rodney Horton from the Texas Cardiac Arrhythmia Institute in Austin, TX, demonstrated in a live case how to isolate the Left Atrial Appendage (LAA) using Radio Frequency (RF) energy.

Side note: If you been in the EP lab before, the first thing you notice when viewing Dr. Horton at work is no one is wearing the lead aprons and protectors required when using fluoroscopy (x-ray). That’s because he uses 3D non-fluoroscopy (no radiation) imaging techniques.

Patient background: An 82-year old male with persistent A-Fib had a previous PVI but still had Flutter. He was also hypertensive. He also had a dual chamber pacemaker. Previously Dr. Horton had isolated the patient’s Coronary Sinus but hadn’t worked on his LAA.

Before the live case, Dr. Horton found that the patient had re-connection in one vein which he isolated before the live case demonstration began.

The Live Case: Mapping and Isolating the LAA

Live Streaming Video from AF Symposium at A-Fib.com

Live Streaming Video at AF Symposium

Dr. Horton used a mapping catheter in the Left Atrial Appendage (LAA).

To isolate the LAA, he used 40 watts radio frequency (RF) energy and a contact force sensing catheter with pressure readings above 10 but not higher than 25. The pressure readings indicate how hard the EP is pressing on the RF catheter to make a particular burn.

He discussed that if the LAA wasn’t contracting properly after the ablation, the patient would have to be on anticoagulation for life. (He, of course, discussed this possibility with the patient before the ablation.)

Dr. Horton rarely isolates the LAA during a first ablation unless he is absolutely sure it needs to be done. He stressed that the phrenic nerve often drops over the top of the LAA. For that reason, he doesn’t ablate too deep into the LAA but ablates at the base of the LAA. 

…he isolated the LAA and the Flutter disappeared as we watched.

Applause, Applause

There was excitement and clapping when he isolated the LAA and the Flutter disappeared as we watched.

Dr. Horton demonstrated for all the attendees that the LAA should also be mapped and isolated. And that isolating the LAA can be very effective in returning a patient to normal sinus rhythm.

Editor’s Comments:
No, no to Fluoroscopy: It’s a type of X-ray and its effect is cumulative. Therefore it should be avoided if possible. (Hence, the need for the staff to wear the lead aprons.)
Instead of fluoroscopy, Dr. Horton uses a non-radiation 3D imaging technique called Intracardiac Echocardiography (ICE), a form of ultrasound.
On a personal note, Dr. Horton has said that not having to wear those heavy lead aprons would probably add 5-10 years to his ablation career.
Importance of the LAA in Isolating A-Fib: More and more EPs are realizing how important the LAA is in mapping and isolating non-PV triggers. Many Master EPs after isolating the PVs, now go right to the LAA as their second isolation target.
What this means for patients: When selecting an EP for your catheter ablation, discuss the Left Atrial Appendage (LAA) as a possible site of non-PV A-Fib triggers. Ask your EP:
 “During my ablation, when you’re looking for non-PV triggers, will you also map and isolated the LAA, if necessary?” (You want an affirmative answer to your question.)

If you find any errors on this page, email us. Y Last updated: Sunday, February 25, 2018

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2018 AF Symposium Live Case: RADAR―A Software Breakthrough in Identifying A-Fib Rotors and Drivers?

by Steve S. Ryan, PhD

RADAR’ may lead to the next big breakthrough in electro-magnetic imaging analysis software for mapping and ablating A-Fib rotors and drivers.

RADAR Clinical Trial

RADAR stands for Real-Time Electrogram Analysis for Drivers of AtRial Fibrillation.

The RADAR Clinical Trial is a prospective, non-randomized, investigational device exemption (IDE) study evaluating new analysis software in patients undergoing catheter ablation for persistent Atrial Fibrillation. This special software algorithm is made by AFTx, Inc.

A-Fib Pattern Recognition Algorithm

The software employs an A-Fib pattern recognition algorithm which can assess what is happening in a particular location within the heart. Then it geometrically stitches together the whole heart chamber to the highest available contact electrograms which results in a high-density 3-D map of the atrium in A-Fib.

Dr. Vivek Reddy from Mount Sinai, New York City, calls the resulting map a ‘PADA’ (probabilistic atrial driver assessment) map showing rotors and focal impulse areas.

The Live Case Using the AFTx RADAR System

Petr Neuzil, MD

Dr. Reddy introduced Dr. Petr Neuzil from Prague, Czech Republic who performed the live case.

Patient Background: The patient was in paroxysmal A-Fib but had suffered a stroke in November 2017 and was on anticoagulants.

First, a standard PVI was performed. Then the spiral mapping catheter was used to map and ablate non-PV triggers (using the Abbott EnSite Precision™ cardiac mapping system).

The AFTx RADAR system uses a 20-pole spiral multielectrode mapping catheter within the heart. (In contrast, the recently developed ECGi CardioInsight [Medtronic] uses a multielectrode vest to capture ECG far-field signals from the body surface.)

Live Streaming Video from AF Symposium at A-Fib.com

Live Streaming Video at AF Symposium

Lesion Indicators: Green, Blue and Red Dots

While watching the live case, when an effective transmural ablation was completed, a green dot appeared. After several ablation applications, a line appeared to connect the green dots. This apparently made it much easier to assess contiguous lesions.

A blue dot represented the latest ablation point. A red dot indicated a possible non-transmural lesion.

Dr. Neuzil’s surgical team in Prague was still ablating the patient when the time block for the live case ran out.

Editor’s Comments:
Making continuous lesions is critical to an effective ablation. But first the ablation sites must be accurately identified and mapped.
Easier and More Reliable: Not only does the RADAR system produce a very accurate, highest density map of the atrium, but the green dots and the visible line between them makes it much easier and more reliable to assess whether lesions are contiguous (no gaps).
History Being Made? Here is yet another instance where attendees at the AF Symposium 2018 were possibly seeing history being made.
The RADAR system may be the next big breakthrough in mapping and ablating A-Fib rotors and drivers and may be a major advance in the treatment of A-Fib.

If you find any errors on this page, email us. Y Last updated: Sunday, February 25, 2018

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2018 AF Symposium Live Case: The DV8 Esophageal Retractor

Background: An esophageal atrial fistula is a very rare (about one in 2,000 cases) but often deadly complication. During a catheter ablation, the esophagus, which rests next to the heart, can be injured when heat from the catheter irritates it. The thermal damage can appear 2-3 weeks after the ablation when a hole forms between the atrium and the esophagus. This weakened area of the esophagus can be eaten through by acid reflex with deadly consequences.
Live Streaming Video from AF Symposium at A-Fib.com

Live Streaming Video at AF Symposium

Demonstrated during a live presentation via streaming video, the DV8 Retractor from Manual Surgical Sciences could eliminate the danger of esophageal atrial fistula. The DV8 Retractor is an inflatable balloon retractor system that moves the esophagus away from the site of ablation.

Drs. Kevin Heist, Conor Barrett and Moussa Mansour from Massachusetts General in Boston, MA demonstrated this simple, effective way of protecting the Esophagus from thermal injury during an ablation.

We watched as Dr. Heist and his colleagues inserted what looked like a thin straight silicon tube into the patient’s esophagus. (The esophagus is a flexible structure and moves naturally.) They then inflated the device which formed a bend or loop and pushed the esophagus as much as 40 mm away from the ablation site. The device could also be maneuvered up and down to further increase the deflection from the ablation site.

DV8 Retractor from Manual Surgical Sciences : Uninflated (L), Inflated (R).

The device has two ports―one for balloon inflation/deflation and a separate one for contrast injection into the esophagus to check placement.

Dr. Mansour stressed that this device should be used in all ablations. Even though esophageal fistula is a very rare complication (around one in 2,000 cases), there is now no reason for the esophagus to ever be damaged during an ablation.

Editor’s comments: Unfortunately there is no way to require EPs to learn about and used this device.
What this means to patients: If you are having an ablation, make sure your center and EP have and use this or another esophageal protection device. If they don’t, you shouldn’t proceed. You MUST go elsewhere where they do!!! It makes no sense to risk an esophageal injury when it is so easily prevented.

If you find any errors on this page, email us. Y Last updated: Saturday, February 24, 2018

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2018 AF Symposium Debate: ‘Can Anticoagulants be Stopped after AF Ablation?’

A topic of great interest to A-Fib patients. An interesting debate between Dr. Francis Marchlinski of the Un. of Pennsylvania Health Center in Philadelphia, PA and Dr. Elaine M. Hylek of Boston Un. Medical Center.

“Can Anticoagulants be Stopped after AF Ablation?”

• Dr. Francis Marchlinski took the “Yes” position (anticoagulation can be stopped).
• Dr. Elaine M. Hylek took the “No” position (anticoagulation should not be stopped).

(Though labeled a “debate”, there was no debate winner or loser; It was a more dramatic way of presenting different views on ablation.)

Dr. Marchlinski began by describing what he hears from patients, that they don’t want to be on anticoagulants. They ask me, “Doc, would you use anticoagulation if I didn’t have A-Fib? Because I’m telling you, I’m not having Atrial Fibrillation.”

In general, he said patients don’t want to have to take anticoagulants, especially after a successful ablation when they are A-Fib free. They are reluctant to take anticoagulation in the absence of EKG and other methods of monitoring when combined with no symptoms of A-Fib.

Pro: Stop Anticoagulation after Ablation

Dr. Marchlinski spoke first in favor of stopping anticoagulation. He anticipated several points that Dr. Hylek might argue, then added his response. ‘Dr. Hylek might say’…

• …there are no randomized studies proving that anticoagulation can be safely stopped after a successful ablation. True, he said. (Later in the debate, he and Dr. Hylek both agreed on this point.)

• …there are some observational studies and registries that indicate there is a high risk of stroke when stopping anticoagulation after an ablation. He countered by pointing out that many of these studies included patients who still had A-Fib after their ablation. …Continue reading this report->

2018 AF Symposium: A Friendly Debate “Can Anticoagulants Be Stopped After AF Ablation?”

by Steve Ryan

An especially interesting presentation at the 2018 AF Symposium was a friendly debate between Dr. Francis Marchlinski of the Un. of Pennsylvania Health Center in Philadelphia, PA and Dr. Elaine M. Hylek of Boston Un. Medical Center. This is a topic of great interest to A-Fib patients:

 “Can Anticoagulants be Stopped after AF Ablation?”

• Dr. Francis Marchlinski took the “Yes” position (anticoagulation can be stopped).
• Dr. Elaine M. Hylek took the “No” position (anticoagulation should not be stopped).

Though labeled a friendly “debate”, there was no debate winner or loser; It was a more dramatic way of presenting different views on anticoagulation and ablation.

Dr. Marchlinski described what he hears from patients, that they don’t want to be on anticoagulants. They ask me, “Doc, would you use anticoagulation if I didn’t have A-Fib? Because I’m telling you, I’m not having Atrial Fibrillation.”

In general, he said patients don’t want to have to take anticoagulants, especially after a successful ablation when they are A-Fib free. They are reluctant to take anticoagulation in the absence of EKG and other methods of monitoring when combined with no symptoms of A-Fib.

Note: Usually the first person in a debate is at a disadvantage. But Dr. Marchlinski instead anticipated what points Dr. Hylek would make and addressed them in his presentation.

Pro: Stop Anticoagulation after Ablation

Francis Marchlinski, MD

Dr. Marchlinski spoke in favor of stopping anticoagulation. He anticipated several points that Dr. Hylek might argue, then added his response. ‘Dr. Hylek might say’…

• …there are no randomized studies proving that anticoagulation can be safely stopped after a successful ablation. True, he said. (Later in the debate, he and Dr. Hylek both agreed on this point.)

• …there are some observational studies and registries that indicate there is a high risk of stroke when stopping anticoagulation after an ablation. He countered by pointing out that many of these studies included patients who still had A-Fib after their ablation.

• …every ablation has recurrences of A-Fib. He said, not in his practice. And in general, this is simply not true. A-Fib ablation has improved significantly over the years.

• …recurrences can be asymptomatic. True, so he trains his patients to use pulse assessment and other methods to check for heartbeat irregularities, and if found, to get in touch with his office. He pointed out that the field of monitoring and the increased variety of monitors available makes it less likely that long periods of A-Fib will go unnoticed.

• …A-Fib is a marker for more serious heart remodeling problems like cardiomyopathy, enlarged left atrium, inadequate left atrial contraction, etc. and therefore patients should be on anticoagulants. He countered by describing how carefully he and most other EPs examine a patient’s heart before, during and after an ablation. If any patient has any serious underlying heart problem, they are monitored life-long and are often on anticoagulants for life.

• He described using NOACs as a pill-in-the-pocket in certain cases when a patient has a recurrence, so that the patient doesn’t have to be on anticoagulants all the time.

• Bleeding risk is still significant, he noted, although the NOACs in general tested better than warfarin.

Con: Continue Anticoagulation after Ablation

Elaine M Hylek, MD

Dr. Hylek stressed that anticoagulation should not be stopped after an ablation. Her main points were:

• There is no way to reliably predict recurrences of A-Fib after an ablation. She encouraged the development of a predictive model.

• Pulse assessment is not reliable. Too many patients can’t recognize ectopic beats, for example.

• She discussed how serious heart remodeling problems can underlie A-Fib, and that these can cause strokes.

• Current monitoring is variable and unreliable. We need larger studies to improve this field.

• She cited a study of what she called “wake up strokes” where a patient wakes up in the morning and has suffered a stroke. By then it’s usually too late to be of much help. She indicated that 25% of strokes are these “wake up strokes.” She stressed how EPs need to do sleep apnea studies on A-Fib patients. [Many centers in the U.S. now automatically send anyone with A-Fib to a sleep apnea center for a study.]

Note: Though labeled a friendly “debate”, there was no debate winner or loser; It was just a more dramatic way of presenting different views on taking anticoagulants and catheter ablation.
Editor’s Comments:
(Just between you and me, I think Dr. Marchlinski won the debate.)
Patients don’t want to take anticoagulants after a successful ablation: The most telling point Dr. Marchlinski made was describing how most patients don’t want to take anticoagulants, especially after a successful ablation. In fact, one of the reasons patients have an ablation is to no longer have to take anticoagulants (and all the other A-Fib drugs which have so many bad side effects and long-term consequences.)
Recurrences are decreasing as ablation improves: With the use of contact force sensor catheters, Cryo and Laser Balloon ablation, advanced mapping techniques, etc., recurrence of A-Fib after an ablation has decreased significantly.
A-Fib patients aren’t dumb and can learn to take their pulse: Most patients are smart enough to take their own pulse or use today’s portable DIY monitors to tell if they are in A-Fib.
Anticoagulants are high risk drugs: Dr. Hylek didn’t discuss the dangers or acknowledge that anticoagulants are high risk drugs which can cause bleeding problems. For more about how NOACs dosage levels may also need to monitored, see the posted article: New Oral Anticoagulants Can Require Careful Dosing Too on the AFA discussion page.

Disclosures: Dr. Hylek lists in her disclosure statement extensive ties to the pharmaceutical industry; Dr. Marchlinski lists ties to medical device makers.

If you find any errors on this page, email us. Y Last updated: Wednesday, February 21, 2018

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